Agenda - Council - 01/11/2005 - Laserfiche WebLink

Home

Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee $50 An exempt permit may be issued to nonprOfit organizations conducting lawful gambling activityon five or fewer days, and awarding less than $50,000 in prizes during a calendar year. Organization Information Organization legal name Street Name of chief executive officer (CEO) First name Page 1 of 2 11/04 IFor Board Use Only Fee Paid Check No. / Previo~s license or exemption number, if any City r ' ' / 'P l--c°un~ . Las[ name Daytime phone number Type of nonprofit organization (check one) [] Fraternal [] Relig!ous [] Veteran ~. Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions) [] Nonprofit Adicles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office [] Internal Revenue Service [~ Affiliate of parent nonprofit organization (charter). Gambling Premises InformatiOn Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Address (do not use PO box) I City Date(s) of acti¥(ty (for ra~es, indicate the date of the drawing) Zip code J County Check the box or boxes that indicate the type of gambling activity your organization will be conducting: [] *Bingo ~ Raffles [] *Paddlewheels [] *Puli-Tabs [] *Tipboards *Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb, state.mn.us and click o~ List of Licensed Distributors. Or call 651-639-4000. This form will be made available in altemative Your name an8 an(J yourorganization's name the .following: Board members, staff of the format (i.e. large print, Braille) upon request, and address will be public information when Board whose work assignment requires that The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be able to process your applicalion. received bylhe Board. Ali the other information that you provide will be pdvate data about you until Ihe Board issues your permit. When the Board issues yOUr permit, all of the informalJon lhat you'have provided to the Board in the process ofapC_ying foryour permit will become public. If the;Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order, other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.